Decreasing Antibiotic Prescribing in Acute Respiratory Infections Through Nurse Driven Clinical Decision Support

Not Applicable

Interventions: Other: Integrated clinical prediction rule (iCPR) system (iCPR)

Brief Summary: This study evaluates the effects of a novel integrated clinical prediction tool on antibiotic prescription patterns of nurses for acute respiratory infections (ARIs). The intervention is an EHR-integrated risk calculator and order set to help guide appropriate, evidence-based antibiotic prescriptions for patients presenting with ARI symptoms.

Detailed Description: The proposed project will fill a critical gap in the evidence base and answer the important question: can pivoting ARI CDS tools towards nurses overcome established implementation barriers to reducing antibiotic use? The proposal is highly innovative in three ways: It uses CDS tools to embed evidence-based risk stratification to enable nurse-led ARI management. It creates a nurse training program to support this nurse-led ARI treatment pathway. It will be evaluated and optimized using evidence-based implementation frameworks that will guide assessment of the fidelity, acceptability, adoption, cost, and sustainability of the tool. This will provide comprehensive implementation measures, formative and summative, and enable a rigorous understanding of barriers and facilitators to implementing nurse-led CDS tools for reducing antibiotic overprescribing. This study will provide much needed guidance on how to implement CDS-enabled, nurse-led ARI assessment and treatment to reduce antibiotic overprescribing.

Recruitment & Eligibility

Inclusion Criteria

Clinics:

Nurses :

be licensed to see patients and prescribed and/or recommend prescriptions for patients
work a minimum of 0.5 FTE to ensure that they are seeing sufficient numbers of patients to maintain competency
have access to the clinic EHR system, and use regularly as part of patient care

Patients:

patients must have been seen at a participating clinic with a complaint of cough or sore throat.
Ages 3-70 will be included for sore throat and ages 18-70 for cough

Exclusion Criteria

are unable or unwilling to provide informed consent
are unable to participate meaningfully in an intervention that involves self-monitoring using software available in English (e.g., due to uncorrected sight impairment, illiterate, non-English-speaking, dementia)
clinics will be excluded if phone call triage of patients with sore throat and cough is not performed by RNs
Nurses will be excluded if they do not work with the clinic EHR as part of their workflow
Patients with a history of chronic lung disease or immunosuppression will be excluded since the CPRs were not validated in these groups

Arm && Interventions

Group	Intervention	Description
iCPR group	Integrated clinical prediction rule (iCPR) system (iCPR)	Clinic personnel (Providers and Nurses) will receive online training that includes: 1) an overview of the project; 2) iCPR workflows including triage; 3) CPR component review and risk categories; 4) history and physical examination components of the CPRs. The online training will be followed by in-person training to reinforce the online training and teach additional skills. In-person training sessions led by study team will last approximately 60 minutes, and consist of four basic components: 1) a review of the iCPR ARI protocol and tools; 2) on-screen walk-throughs of common scenarios employing the new tools; 3) physical examination technique practice with simulated patients; A 60-minute in-person follow-up nurse training will take place 4-6 weeks after implementation of the intervention.

Primary Outcome Measures

Name	Time	Method
Number of Participants Who Perceive the iCPR Tool as Useful.	Month 6	Participants will be interviewed to measure the usefulness of the iCPR tool in prescribing appropriate antibiotics.
Change in number of Acute Respiratory Infection(ARI) encounters	Baseline, Month 36	The number of Acute Respiratory Infection(ARI) encounters with inappropriate antibiotic prescription will be measured pre and post-intervention using EHR reports assessing ordering of antibiotics

Secondary Outcome Measures

Name	Time	Method
Number of patients requiring repeat healthcare visits	week 2	Adoption of using iCPR tool will be measured by the number of patients requiring repeat healthcare visits through extracted EHR data.
Change in Job Satisfaction of RNs and physicians	Baseline, Month 6, Month 12	Job satisfaction/ burnout of the RNs and physicians in enrolled clinics will be measured qualitatively with interviews at baseline, 6, and 12 months after implementation
Number of nurse triage encounters completed	Week 2	Adoption of using iCPR tool will be measured by the number of nurse triage encounters completed through extracted EHR data.

Locations (3): University of Wisconsin
🇺🇸
Madison, Wisconsin, United States
University of Utah School of Medicine
🇺🇸
Salt Lake City, Utah, United States
NYU Langone Health
🇺🇸
New York, New York, United States